October 7, 2026

Leadership Ledger: Echo Cliffs and Sage Memorial – PL 93-638 Answering the Question

Oct 7, 2026 | Anthony Craig Locklear II

Two days on the Navajo Nation

At our National Tribal Health Conference in Chandler this August, someone in the room asked a question I have not been able to set down: where are our babies going to be born? I have been pairing it with a second one. Will we be able to keep our elders at home?

On October 1 and 2, I spent two days on the Navajo Nation watching two Tribal health organizations answer those questions in real time. Thursday was a site visit to Sage Memorial Hospital in Ganado with my colleague Kristen Bitsuie. Friday, I was honored to speak at the grand opening of the Echo Cliffs Health Center in Coppermine. Both are run under Public Law 93-638, the Indian Self-Determination and Education Assistance Act. Both are proof of what Tribes build when they hold the authority and the funding to build it.

Echo Cliffs: A Clinic The Elders Asked For

The Echo Cliffs Health Center opened on October 2, 2026, in the Bodaway/Gap community of Western Navajo. It is a 123,000-square-foot outpatient center led by Tuba City Regional Health Care Corporation, with primary care, pediatrics, women’s health, dental, eye care, pharmacy, physical therapy and behavioral health for Navajo, Hopi and San Juan Southern Paiute families in Cameron, LeChee, Coppermine, Page and the communities around them.

The idea is older than the building by decades. It began as a resolution from local elders, many of whom did not live to see the ribbon cut. Their patience was forced on them. Bodaway/Gap sits inside the former Bennett Freeze, a federal development ban the Bureau of Indian Affairs imposed in 1966 on 1.5 million acres of Western Navajo during the Navajo-Hopi land dispute. For 43 years families there could not build, and often could not repair, their own homes. Congress repealed the freeze in 2009. Seventeen years later, there is a health center on N20.

TCRHCC broke ground in February 2024. The project also includes 92 homes for clinical staff, 60 apartments and 32 single-family houses, funded by the Indian Health Service. That detail matters more than it sounds. You cannot recruit a provider to a place with nowhere to live, and TCRHCC planned for it from the start.

TCRHCC itself is a 638 story. The Tuba City hospital was an IHS facility until September 30, 2002, when the Navajo Nation Council approved its transfer to a local, community-governed corporation. Twenty-four years later, that corporation runs a regional referral hospital and the only Level III trauma center serving Native people outside Anchorage, and it just opened a new front door much closer to families at the northern end of its service area.

When I spoke on Friday, I came back to the question from NTHC. Echo Cliffs is an outpatient center, so babies will still be delivered in Tuba City. What changes is everything before that day. An expecting mother in Coppermine can get her prenatal and women’s health care down the road. That is how a Tribal organization answers the question: by putting care where the families already are.

Mr. Jerry Freddie was there, a former NIHB board member and a recipient of the Jake Whitecrow Award, the highest honor in Indian health. Clinics like Echo Cliffs exist because elders like him spent decades pushing for Indian health in rooms that did not always want to hear it, long before anyone was cutting ribbons. When NIHB walks into a congressional office to ask for facilities money, we carry Mr. Freddie and the Bodaway/Gap elders in with us. We are finishing work they started.

Sage Memorial: The Birth and The Sacred Age

Sage Memorial Hospital in Ganado is a 16-bed critical access hospital run by the Navajo Health Foundation under a 638 agreement. It will mark 100 years in 2030, and it is the only hospital on the Navajo Nation that serves both Native beneficiaries and non-Native patients from the surrounding communities. Its board, its CEO and its executive team are Diné, and so are about 89 percent of its employees.

Board Chair Delores Noble opened our morning with the Long Walk. She talked about Diné families forced across the Rio Grande in 1864, about elders who could not keep up and children born along the way. The people who made it home, she said, are survivors, and the generation in that room is the one that overcame. Because Navajo people know what it felt like when the federal government provided only the minimum, she said they owe their own people the best care there is. Then she said the thing I have carried since. In Diné teaching, two parts of life are held sacred: the birth, and the sacred age. Everything in between is the work. She had answered both of the questions we brought home from NTHC.

The people running Sage carry that in their own stories. CEO Melinda White was born at the old Sage hospital, and her first job there was as a volunteer file clerk. After 20 years as a nurse, she runs the place. Traditional practitioner Harrison Jim came in 2014 to rebuild the hospital’s traditional healing program, ceremonies and sweat lodge included. Sage may be the only hospital with a full-time policy advisor, Kim Russell, who has taken its story to the Arizona legislature and to the Hill. And the staff take a pledge to treat everyone who walks in as a relative, not a patient.

The results show it. Sage opened a new $177 million hospital in December 2024. Since then it has added surgical services, podiatry, telehealth specialty care, tele-ICU and swing beds, and those additions have changed what a 16-bed hospital can do. Patients who used to be sent out for a specialist now see one without leaving Ganado. Between July 2025 and July 2026, total visits rose 22 percent, from 51,023 to 62,446, and behavioral health visits rose 51 percent. In fiscal year 2024 the average inpatient census was close to zero. This year it is 11.2 patients a day, and on some days Sage is transferring people out because every bed is full. Its most recent Joint Commission survey turned up one finding for its primary care home, where Melinda said she is used to seeing 20 or 30.

Next is labor and delivery. Sage already provides prenatal and postnatal care and is recruiting one more OB to open the unit, which leadership expects will see about 40 births a year. We stood in one of the new delivery rooms. It has a floor-to-ceiling window that looks straight out at the red mesas around Ganado. A Diné mother will be able to bring her child into the world looking out at her own homeland. I have been in a lot of hospitals. I have never seen a room that answers the question so plainly.

Then there is the sacred age. Sage runs the only inpatient dialysis on the Navajo Nation. About 1,372 of its patients are 70 or older, and with only one nursing home on the entire Nation, elders get sent to Winslow, Show Low or Phoenix, away from their families. So Sage is opening an elder day program, As’ah Dilzin, in January 2027, with respite care to follow and skilled nursing as the goal. Medicare does not pay for adult day or respite care. Sage is paying for it anyway.

Sage’s leadership also walked us through the pressures they are carrying, including Medicare Advantage practices that strain small Tribal hospitals, timely payment of contract support costs, and federal and state funding that does not match what it takes to run a hospital on the Navajo Nation. These are the same issues we hear from Tribal health systems across the country, and they shape the case NIHB makes in Washington.

What it takes to keep answering

Neither of these places waited for permission. TCRHCC planned staff housing before the clinic opened. Sage built elder care with no reimbursement behind it and uses 105(l) leases to put new buildings into service. That is self-determination doing what Congress intended in 1975.

But 638 only works when the federal government holds up its end. Contract support costs paid in full and on time. Facilities money that moves on a timeline elders can live to see. Advance appropriations so a shutdown in Washington does not reach a dialysis chair in Ganado. And Medicare and Medicaid rules that recognize the care Tribes are already providing.

In Coppermine and Ganado, Tribal health systems are answering both questions. NIHB’s job is to make Washington easier to work with for them, and for every Tribe still waiting on its own Echo Cliffs.

Sources